Skip to content
recurance

Madeleine Lawrence

6 Nov 2023 · Coroner Peter Harrowing · Avon

The coroner's concerns

  1. 1. patient safety deficiencies

    “serious deficiencies affecting the safety of patients at Southmead Hospital”
  2. 2. inadequate staff training measures

    “The CQC should confirm that it is now satisfied that the Trust has addressed the training of current staff and has in place appropriate measures to ensure ongoing training for new staff”

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error